RE-ENROLMENT FORM

CHILD ONE surname:

Childs preferred name:
Year Level at school:
CHILD TWO surname:
Childs preferred name:
Year Level at school:
CHILD THREE surname:
Childs preferred name:
Year Level at school:
CHILD FOUR surname:

Childs preferred name:

Year Level at school:

Please list any changes for CHILD details since previous enrolment form (address, etc):



Parents / Guardians:
PARENT ONE name: PARENT TWO name:
List any changes to PARENT contact info (phone, email, etc):



Are there any changes to the custodial arrangements concerning your child?
If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required)


Person/s who cannot pick up your child:
NAME/S:
Emergency Contacts (PLEASE LIST ANY CHANGES):

EMERGENCY ONE name: EMERGENCY TWO name:
List any changes to PARENT contact info (phone, email, etc):





Enrolment Dates:
HOLIDAY DATES (circle date) JANUARY APRIL JULY OCTOBER
Days Monday Tuesday Wednesday Thursday Friday
Tick if attending


CHILDS DOCTOR:
Name: Phone:
Name of medical centre:
HEALTH:
Illness / allergies / behavioural information we need to know about:

MEDICINE REQUIRED:
Please list medicines required and instructions you will also need to fill out our
medicine register each morning when you sign in your child/ren at the programme.



ANY OTHER INFORMATION:
Please list any other info that we need to know about:





IMPORTANT INFORMATION:

If someone other than those named on this form is going to collect your child/ren you MUST
notify us in advance or we will not release your child from our care.
If you allow your child to leave the programme without an adult (walking, biking, etc) we
require verification of this in writing at the time of enrolment.

I give permission for my child/ren named above to participate in the Kidz LIFE and FUSION
programmes. Should emergency care be needed for my child/ren I give permission for the
supervisor to seek medical treatment at my cost.

While all care is taken by Staff and Management I acknowledge, in signing this form, that
neither staff nor management of the programme will be liable for any loss or damage arising
out of attendance at the programme.

Te Aroha Noa collects, records, stores, and uses personal information gathered for Kidz LIFE
and FUSION purposes in accordance with the Privacy Act 1993.

1. I give permission for my child to travel with staff from Kidz Life and Fusion (Te Aroha
Noa employees and/or volunteers). Parents will be notified of specific trip details and
updates will be made on our Facebook page regarding each trip.


2. I give permission for any photographs and/or art work completed by my child/ren to be
used for advertising and promotion of Kidz Life, Fusion, and Te Aroha Noa Community
Services.

POLICY STATEMENT:
Kidz LIFE / FUSION have a number of policies that set out the procedures that are in place
for the care and education of the children who attend. We strongly urge you to read these.
The signing of this enrolment agreement form indicates that you will abide by the policies of
this service, and understand how you can have input to policy review.
Parent Declaration:
I declare that all the above information is true and correct to the best of my knowledge.
Parent/Guardian Signature:

_____________________________

Date: ____ /____ / ____
Service Declaration:
On behalf of Kidz LIFE / FUSION / TE AROHA NOA, I declare that this form has been
checked and all relevant sections have been completed.

Service Provider Signature:
_____________________________


Date: ____ /____ / ____